Rutgers University Occupational Therapy Doctorate Program

Level II Fieldwork Assignments

Facility Overview

Facility Name:
Address:
Facility Phone:
Contact Person:
Name ______________________ Phone __________________________
Site Type: ________________________
Setting: ______________________________________

FACILITY INFORMATION
Building Information
(1 big room, multiple rooms, bathroom set up, wheelchair accessible, etc. What is in the rooms- IE tables, chairs with or
without wheels, computers, TVs, couches, etc)

Materials (what materials did the facility have. IE games, puzzles, balloons, balls, Thera-band, exercise videos, TVs,
computers, etc)

Emergency Exits (where are they in the building. IE 2 exits in front, 2 in back)

Parking (describe parking. IE street, lot, permit needed, free, cost, easy to find, hard to find, need to be there at X time to
find a spot)

TYPICAL DAY INFORMATION

Start Time: ____________________ End Time: _________________________
Time Breakdown (IE 9-9:30 Clients Arrive, 9:30-10 Exercise Group, etc)
9am

STAFF
Number of Staff: How many staff are there on a given day?

Staff Titles: What are their titles (IE director, volunteer, assistant, etc)?

Staff Roles: What their different roles?

Staff Dress Code:

CLIENT POPULATION
Average Number of Clients Per Day: ____________
Age Range Percentages: Ages 65+ _________ Ages 55-64 ___________ Ages 55> ___________

Demographics:
White
Black or African-American
American Indian or Alaskan Native
Asian
Native Hawaiian or other Pacific islander
From multiple races
Some other race (please specify)

Languages Spoken:

Client’s Rationale for Attendance (ask a minimum of 5 clients why they are there every day)
1. X
2. X
3. X
4. X
5. X

EMERGENCY PROCEDURES (what to do if…)

Fire Occurs

Facility Loses Power

Client Falls

Client Passes Out

Client has Medical Issue (heart attack, stroke, difficulty breathing)

SUPERVISION
Who is considered your supervisor? What is their role/ title at the facility?

How frequently do you meet with the supervisor?

How accessible is the supervisor to you? (IE if you has a problem, can you find them or are they always in meetings,
or not in the building)
How much feedback do you get from your supervisor? (Feedback includes directions, compliments, constructive
criticism, client information, tasks given, etc)

How much feedback do you get from the rest of the staff? (Feedback includes directions, compliments,
constructive criticism, client information, tasks given, etc)